Diving Deep on Commonly Encountered Eligibility and Enrollment Issues
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1 Diving Deep on Commonly Encountered Eligibility and Enrollment Issues Center on Budget and Policy Priorities February 26, 2014
2 2 Part I: COBRA COVERAGE OPTIONS
3 3 Open Enrollment: Annual Period When All Eligible Individuals Can Enroll in a Qualified Health Plan Marketplaces will determine eligibility to enroll in a QHP, assess (or determine) eligibility for Medicaid and CHIP, and determine eligibility for premium tax credits and cost-sharing reductions all year. But a person can only enroll in a QHP during open enrollment (unless he/she meets requirements for a special enrollment period ).
4 4 A person must be enrolled in a QHP to receive subsidies Marketplace Plan or QHP Tax Credit and Cost- Sharing Reduction
5 5 Timing can prevent enrollment in a QHP/Marketplace plan Marketplace Plan or QHP Tax Credit and Cost- Sharing Reduction
6 6 Background on COBRA Allows certain former employees and their family members to continue coverage under an employer s health plan. COBRA is offered when a person covered by a group health plan experiences a qualifying event, such as loss of a job (other than for gross misconduct) or a reduction in hours. The ACA treats state continuation coverage or mini-cobra the same as federal COBRA for purposes of this discussion. The employee generally pays full cost of the COBRA premium. COBRA coverage is typically available for a maximum of 18 months.
7 7 Q: Can a person with access to COBRA be eligible for Marketplace subsidies? Yes. The general rule is that being eligible for COBRA coverage does not bar a person from receiving subsidies through the Marketplace. So having the option of COBRA coverage differs from having the option to enroll in regular job-based coverage, which can prevent subsidy eligibility. If a person is enrolled in COBRA he or she cannot get Marketplace subsidies while still enrolled.
8 8 Eligibility for Some Types of Coverage Bars Subsidy Eligibility Employer-sponsored Health Plan
9 9 Having the option to enroll in COBRA does not bar subsidy eligibility COBRA
10 10 A person enrolled in COBRA cannot get subsidies while enrolled COBRA
11 11 Retiree Coverage Works Similarly As with COBRA, being eligible for a retiree plan does not bar a person from receiving subsidies through the Marketplace. Therefore, having the option to enroll in retiree coverage is different than having the option, as an active employee, to enroll in the employer-sponsored coverage, which can be a bar to subsidies.
12 Scenario #1: Shelby has the option to enroll in COBRA Last month she left a job where she had health insurance. Shelby has an offer of COBRA coverage through her former employer, but she finds the cost is too expensive. She hasn t enrolled in it. She wants to see if she qualifies for Marketplace subsidies.
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20 20 Scenario #1: Shelby has the option to enroll in COBRA Shelby s eligibility for COBRA does not prevent her from being eligible for subsidies. To use the subsidies, she would still need a Marketplace plan.
21 21 Q: Can a person enrolled in COBRA drop it and access a Marketplace plan? Right now, yes. During Marketplace open enrollment, someone who is enrolled in COBRA can drop that coverage and enroll in a Marketplace plan. For people getting subsidies, the effective date of Marketplace coverage will be no earlier than the day after the COBRA coverage ends.
22 22 Scenario #2: Shelby has COBRA and it s open enrollment Recently left a job where she had health insurance and now is enrolled in COBRA coverage through that employer. She signed up for COBRA because she didn t know she had another option, but it is very expensive for her. She wants to enroll in a Marketplace plan, possibly with subsidies. It is February Shelby is applying during the Marketplace open enrollment period.
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28 28 Scenario #2: Shelby has COBRA and applies at the Marketplace during open enrollment Result: Shelby can drop her COBRA coverage and because it is open enrollment in the Marketplace enroll in a QHP and receive the subsidies she is eligible for.
29 29 Q: How does the treatment of COBRA change after the Marketplace open enrollment period ends? The option to enroll in COBRA does not stop someone from being eligible for a Marketplace plan, including after open enrollment ends. However, if a person is enrolled in COBRA, dropping this coverage will not qualify her for a special enrollment period. Outside of open enrollment, she may have to wait until the next open enrollment period to get a Marketplace plan.
30 30 Scenario #3: Shelby has COBRA, Marketplace open enrollment is over Left a prior job with health insurance and is enrolled in COBRA coverage through that employer. Wants to enroll in a Marketplace plan and has income in the subsidy range. It is April 2014, so Shelby is applying at the Marketplace after the annual open enrollment period has closed.
31 31 Scenario #3: Shelby has COBRA, Marketplace open enrollment is over Dropping COBRA does not trigger a special enrollment period. Shelby isn t able to enroll in a Marketplace plan, so she can t access the subsidies.
32 32 Options for Shelby if she has COBRA and Marketplace open enrollment is over Wait until the next open enrollment period to acquire 2015 Marketplace coverage with a subsidy. Continue COBRA until it runs out (usually a total of 18 months). Note that if Shelby experiences an event that does trigger a special enrollment period in the Marketplace (i.e., permanent move to an area with a different array of Marketplace plans, marriage, etc.) she can enroll in a QHP without waiting until the next open enrollment period.
33 33 Scenario #4: Marketplace open enrollment is over, Shelby is losing her job-based coverage Shelby is leaving her job and losing her employer-sponsored health insurance. Her employer has offered her COBRA. Marketplace open enrollment is over for the year, but Shelby s loss of her employer coverage also triggers a special enrollment period in the Marketplace. She weighs both options and decides which is best for her.
34 34 CMS Fact Sheet and COBRA
35 35 Section II: HEALTH COVERAGE FOR YOUNG ADULTS AND STUDENTS
36 36 Determining Eligibility Requires Piecing Together Different Rules and Requirements IRS Health Insurance Marketplace Medicaid
37 37 Mapping Out Different Definitions and Requirements Dependent Coverage Qualifying Child or Relative for Tax Medicaid Household Definition of Child Biological or adopted Qualifying children include biological, step, adopted or foster child, sibling, niece or nephew, or grandchild Biological, step or adopted child Age Limit Children must be under 26 to be eligible for dependent coverage Children must be under 19 (or 24 if FT student) to be claimed as qualifying child No age limit on being claimed as a qualifying relative No age limit for applying the tax dependent rule to child dependents For applying the nonfiler rule, children are under 19 or at state option, under 19 or 21 if FT student
38 38 Confusion About Coverage Dependent vs. Tax Dependent A 24-year-old lives on his own but is a dependent on his parent s employer plan. Can he qualify for premium tax credits? How does the requirement for insurers that offer dependent coverage to cover children up to age 26 affect premium credit eligibility for these adult children? If an adult child (age 26 or older) is living in her parents home and is properly claimed as a tax dependent by her parents, can she qualify for premium tax credits?
39 39 Dependents for Purposes of Coverage A coverage dependent is the child (biological or adopted) of the participant (subscriber) who is under age 26. Group health plans and health insurance issuers can choose to define dependents more broadly There can be no additional requirements for considering a child a dependent X X X
40 40 Who Qualifies as a Coverage Dependent? John 24 years old Lives on his own Earns $30,000 Qualify for Dependent Coverage? Yes Jane 27 years old Lives with parents In law school No earnings Leena 5 years old Lives with aunt Under guardianship of her aunt Qualify for Dependent Coverage? No Qualify for Dependent Coverage? No
41 41 Dependents for Purposes of Taxes A tax dependent is a person, other than the tax filer or tax filer s spouse, for whom the tax filer can claim an exemption. There are two kinds of tax dependents: Qualifying child Qualifying relative
42 Who Can Be a Qualifying Child? 42
43 Who Can Be a Qualifying Relative? 43
44 44 Can John Be Claimed as a Tax Dependent? John 24 years old Lives on his own Earns $30,000
45 45 Can John Be Claimed as a Tax Dependent? John 24 years old Lives on his own Earns $30,000 John cannot be claimed as a tax dependent
46 46 Can Jane Be Claimed as a Tax Dependent? Jane 27 years old Lives with parents In law school, no earnings
47 47 Can Jane Be Claimed as a Tax Dependent? Jane 27 years old Lives with parents In law school, no earnings Jane can be claimed as a tax dependent
48 48 Can Leena Be Claimed as a Tax Dependent? Leena 5 years old Under guardianship of her aunt Leena can be claimed as a tax dependent
49 49 What Coverage Choices Does John Have? John 24 years old Lives on his own Earns $30,000 Can be a coverage dependent Tax filer, not claimed as a dependent Parents Coverage Marketplace Coverage John can get on his parents plan because he is under 26. The offer does not make John ineligible for a Premium Tax Credit. John can apply for Premium Tax Credits and Cost-Sharing Reductions. His expected contribution for the benchmark plan is $2,545 per year.
50 50 What Coverage Choices Does Jane Have? Jane 27 years old Lives with parents In law school No earnings Cannot be a coverage dependent Claimed as tax dependent by parents Parents Coverage Student Coverage Marketplace Coverage Jane cannot get on her parents coverage because she is not under 26 years old. Jane can enroll in her university s student health plan. This qualifies as Minimum Essential Coverage but doesn t make Jane ineligible for PTCs. Jane can apply for Medicaid or PTCs. Her parents income will be counted towards her eligibility because she is their dependent
51 51 What Coverage Choices Does Leena Have? Leena 5 years old Under guardianship of her aunt Not a coverage dependent on her aunt s employer plan Claimed as tax dependent by aunt Aunt s Coverage Medicaid / Marketplace Coverage Leena is not eligible to enroll in her aunt s coverage because her aunt s employer does not offer dependent coverage for nonchildren. Leena will be eligible for Medicaid. Her aunts income will be not counted because Leena is a dependent who is not the child of the taxpayer (her aunt)
52 52 Confusion About When to Apply Definitions of Child in Determining Medicaid Households How does Medicaid determine the household of an adult claimed by her parents as a tax dependent? Is she a separate household? Or is she the household of her parents who claim her?
53 53 Who Is in a Medicaid Household? If an individual expects to be a: Tax Filer Not Claimed as a Dependent Tax Dependent Non-Filer / Non-Dependent Individual s household is: Tax filer and all persons whom taxpayer expects to claim as a dependent SPECIAL RULES For married couples filing jointly, each spouse is considered a tax filer Married couples living together are always in each other s household regardless of how they file Individual s household is: The household of the tax filer claiming individual as a dependent EXCEPTIONS (apply the rules for non-filer) Tax dependents not a child or spouse of the taxpayer Children living with both parents not expected to file a joint return Children claimed as tax dependent by non-custodial parents For adults: Household is the individual plus, if living with individual, spouse and children For children: Household is the child plus siblings and parents (including step-parents) living with child At state option, children are either Under age 19, or Under age 19, or full-time students under age 21
54 54 How Does Medicaid Evaluate Jane s Eligibility? Jane 27 years old Lives with parents In law school No earnings Cannot be a coverage dependent Claimed as tax dependent by parents Apply tax dependent rule Jane s household is the household of her parents who claim her Does not matter that Jane is claimed as a qualifying relative as opposed to a qualifying child Does not matter that Jane is over age 19
55 55 Confusion About Coverage and the Eligibility Process for Out-of-State Students An 18-year-old attends college in a different state from where his parents live. His parents claim him as a dependent on their tax return. Of which state is he a resident? In which state does he apply for coverage? Is he included in the household of his parents or is he his own household?
56 56 Eligibility for a Family with Dependent Child Attending College Out of State Gilberto, Sonia, Marco, and Ana Reyes Gilberto, Sonia, are married filing jointly Claim both children What are the Reyes family s Medicaid and premium tax credit household? They are all a household of four. Of which state is Marco a resident? Marco attends college out of state Ana lives at home Marco can declare the state in which he intends to live and remain as his state of residence. That can be the state where his parents live, or the state where he attends college.
57 57 What Are the Implications of Declaring Residency in Another State? If Marco declares the state in which he goes to school as his residence, does he become a household of one? No. Residing in a different state from his parents does not change his Medicaid or PTC household, which is based on his tax filing status. If Marco declares residency in another state, how would the family apply? Gilberto and Sonia would submit an application in the state where they live. Marco would submit a separate application for himself to the Medicaid agency or Marketplace where he lives.
58 58 Section III: REPORTING CHANGES IN CIRCUMSTANCES
59 New healthcare.gov functionality 59
60 60 Changes affecting eligibility Life changes that affect eligibility must be reported within 30 days. This includes: Changes in income Changes in who is in the household Changes regarding the availability of minimum essential coverage Changes will be verified by the Marketplace and eligibility will be re-determined based on the new information
61 61 Changes in income A new monthly APTC is calculated based on: the new estimate of annual income the amount of APTC that has already been received When John enrolled in Marketplace coverage in Nov. 2013, he projected an income of $20,000 for On May 1, John started a new job with a salary of $30,000. He reported the change to the Marketplace. Original APTC calculation Income: $20,000 Household: 1 APTC: $1,514/yr ($126/mo) Jan Feb Mar April May June July Aug Sept Oct Nov Dec Monthly $20k $1,667/mo x 4 = $6,668 Monthly $30k $2,500/mo x 8 = $20,000
62 62 Changes in income A new monthly APTC is calculated based on: the new estimate of annual income the amount of APTC that has already been received When John enrolled in Marketplace coverage in Nov. 2013, he projected an income of $20,000 for Original APTC calculation Income: $20,000 Household: 1 APTC: $1,514/yr ($126/mo) On May 1, John started a new job with a salary of $30,000. He reported the change to the Marketplace. New APTC calculation Income: $26,668 Household: 1 APTC: $556/yr ($46/mo) APTC received Jan: $126 Feb: $126 Mar: $126 Apr: $126 $504 Adjust APTC by amount already received $556 total allowable credit - $504 credit received $ 52 credit remaining ~ $6/mo (or opt to take none)
63 63 Changes in filing status Chuck is separated from his wife but not divorced. They will not file taxes together in Chuck has an adult son, Michael, who is unemployed, has no income and is living with Chuck. They both need health insurance. Chuck plans to file his 2014 taxes as head of household. Original APTC calculation Income: $40,000 Household: 2 APTC: $4,094/yr ($341/mo) Head of Household Rules Must be unmarried OR considered unmarried (lived apart from spouse for the last 6 months of the tax year) Must pay more than half the cost of keeping up the home for a qualifying person Your qualifying child A qualifying relative who is related to you and lived with you for more than 6 months A parent who is a dependent
64 64 Changes in filing status In June, Michael gets a job and will no longer be his father s dependent. Chuck reports this to the Marketplace and his eligibility is redetermined. Chuck cannot be head of household. He is now married filing separately so the Marketplace tells him he is ineligible for premium tax credits. New APTC calculation Income: $40,000 Household: 1 Married Filing Separately
65 65 Changes in dependency Like filing status, dependency is determined at the end of the year for the entire year. (There is no half-year dependent. ) In many cases, dependency will be straightforward But changes can often occur regarding qualifying relatives (unrelated or adult dependents) and older children.
66 66 Example: Katie, the college student Katie is 22-years-old, a full-time student and will graduate with a B.A. in May Katie and her parents are uninsured. Katie s Parents Katie Income: $50,000 Income: $2,500 from a work-study job on campus Tuition: $10,000 $5,000 in academic scholarships $2,000 from Katie s parents $3,000 in Stafford loans in Katie s name
67 67 Student income NOT INCOME Scholarships for tuition if: Student is a degree candidate AND Terms specify that it should be applied to tuition or it can be used for tuition and is not more than tuition Grants Loans What is counted in Katie s income? $2,500 from a work-study job on campus YES $5,000 in academic scholarships NO $2,000 from Katie s parents NO $3,000 in Stafford loans in Katie s name NO INCOME Scholarships for things other than tuition When terms specify that it should be used for anything other than tuition (e.g., room & board, books, etc) Money with a work requirement Will be reported on W-2 as earned income **Not counted as income for Medicaid Federal work-study
68 68 Is Katie a dependent? Living away from home while attending school is a temporary absence and is still considered time in the home. Full-time student = fulltime for at least 5 months of the tax year. Support includes educational expenses. Loans in the child s name are considered the child s own support.
69 69 Is Katie a dependent? Based on what we know right now, Katie might be her parents dependent. Is Katie paying more than half of her own support? SUPPORT TOTAL COST KATIE PAYS Housing & Utilities $600/mo $7,200 $0 Yes, Katie is a dependent. Food Clothing $200/mo $2,400 $150/mo $1,800 $100/mo $1,200 $100/mo $1,200 Medical $2,500 $0 Education $10,000 $3,000 Other $1,000 $500 TOTAL $24,900 $5,900 (21% of total support)
70 70 Is Katie a dependent? Based on what we know right now, Katie might be her parents dependent. Is Katie paying more than half of her own support? SUPPORT TOTAL COST KATIE PAYS Housing & Utilities Food Clothing $600/mo $7,200 $200/mo $2,400 $150/mo $1,800 $0 Medical $2,500 $0 $100/mo $1,200 $100/mo $1,200 Education $10,000 $10,000 Other $1,000 $500 TOTAL $24,900 $12,900 (52% of total support)? But what if. Katie takes out $10,000 in loans instead of $3,000? She is paying more than 50% of her own support. Therefore, she will not be a dependent.
71 71 Katie is a dependent Katie and her parents enroll in Marketplace coverage Is Katie s $2,500 of income added to MAGI? No, Katie s $2,500 income does not create a filing requirement. Household: 3 Income: $50,000 (256% FPL) Premium costs for 3: $10,623 Premium tax credit for 3: $ 6,511 ($543/mo) When does a dependent have a filing requirement? In general, a single dependent under age 65 has a filing requirement if (2013 figures): Earned income >$6,100, OR Unearned income >$1,000, OR Taxable gross income was greater than either: $1,000 or earned income (up to $5,750) plus $350.
72 72 Surprise! Katie gets a job starting September 1. It pays $40k/yr and includes health insurance! Is Katie still a dependent?
73 73 Surprise! Katie gets a job starting September 1. It pays $40k/yr and includes health insurance!. Is Katie still a dependent?
74 74 Change in circumstances Katie s parents report a change in circumstances on September 1. Katie is projected to be a dependent (Jan Aug) Household: 3 Income: $50,000 (256% FPL) Premium costs for 3: $10,623 Premium tax credit for 3: $ 6,511 $543/mo Katie s parents realize she is not a dependent Household: 2 Income: $50,000 (322% FPL) Premium costs for 2: $7,804 Premium tax credit for 2: $3,054 APTC Received $543/mo x 8 mo = $4,340 September 1 Redetermination APTC received (Jan-Aug): $4,340 Maximum PTC for parents: $3,054 $0 PTC allowed for remaining months.
75 75 Contact Information Sarah Lueck, January Angeles, Tara Straw, Halley Cloud, For more information and resources, please visit: This is a project of the Center on Budget and Policy Priorities,
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